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Date�9v <br />Application For <br />PUBLiC WQRKS PERMIi <br />Print or Type Only <br />Owner <br />Describe ProFased Work <br />Project Address (i( known) � <br />ng Address <br />Address <br />l �� <br />Pu�lic Wo�ks Permit s�� <br />Oltlq. L pl.+ � <br />Publl_ Works �oo <br />Tolal Fee $ <br />Lc s Aoo� Fne Pa��l S <br />❑a1:m�eDur �u <br />Zip Phone <br />Cip <br />Attach four (4) copies of plans (or proposed work - Draw to scale and note the follo�•�ing as applicable: <br />• Proparty Lines <br />• Outline and dimensions of all existing and <br />proposed slrucWres on the lol <br />• Exis�ing and proposed utilities <br />• Centerline of sireet <br />• Indicatr North <br />Y Show any proposed gradin9 changes <br />• Show measurements <br />rnone <br />PERMIT CONDITIONS <br />1. All cal;s for inspection shall be made 24 hrs. in advance - phone 259-SS10. <br />2. All ��ork shalf be performed in accordance with this permit and current City of Everett Design and Consiruction <br />Sta�idards and Specifications. <br />3. Call Location llntlerground Service 48 hrs. before you dig. TOLL FREE NUMBER 1-S(10•424-5555. <br />�.lo � �' : <br />Approved lor i;onst <br />�V�jLI L I�Q2K`,� PE�.M!'T- �OT �EC1t1f <br />� U 1 l� L.71 1� C-� <br />1�_►�'l ` �-�. <br />3 �� 3 �SO <br />�"r_-►2. P`'i. l i �t�..vr C�c"i� � <br />F,CKNOWLEDGEMENT OF CONDITIONS <br />"` i <br />The undarsic7ned owner/applicant hereby agrees to hold and save harm- <br />less the City o.' Everet� Irom any and all claims for damages. costs, <br />expenses, or causes oi aclion tha� may arise because of installation <br />and maintenance of thc improvement ar oiher right-ol�w�y use hereto <br />applied for and luriher agrees to remove same upon notice Irom ihe <br />Date CitV ���� to replace public property damage.d �hereby. <br />FINAL INSPECTION Date <br />Approved as Constructed <br />everett PUBLIC WORKS DEPARTMENT <br />� 3200 Cedar Streel <br />Everelt, WA 98201 <br />Phone:259-0810 <br />Si�na�ure ol AppliCan� "�" <br />WORK AUTFiORIZED BY THIS PERMIT MUST BE STARTED WITHIN <br />180 DAVS OF DATE PERMITIS ISSUED AND THEREAFTER IS TO <br />BE DILIGENTLY PURSUED TO COMPLETION. THIS PERMIT MAY BE <br />CANCELLED BY TH[ CITY UPON ANY STOPPAGE OF WORK ON THIS <br />PROJGCT OVER 90 DAVS DURATI�N. <br />